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Based on document review and on site observations of fire rated partitions, the facility failed to provide/ maintain the designated rated separation walls. This deficient practice could affect patients, staff and visitors if a fire were to spread without properly maintained fire separation.

Findings include:

On 11/1/16 at 10:31 AM while accompanied by FM and DSS, in review of the Life Safety drawings on the North side of the Main Building, 1st floor, which indicated a 2-hour rated wall by room 1627. Unsealed pipe penetration and 3 unsealed holes were observed in the rated wall above the cross corridor doors. This does not comply with NFPA 101, 8.3.1.1.

Based on observation during the survey walk-thru, means of egress components are not installed correctly. This deficient practice could affect patients, staff and visitors if a failure to maintain the means of egress compromises prompt and unimpeded egress from a room or area during a fire/smoke event.

Findings include:

On 11/1/16 at 11:00am while accompanied by the VPO & POM2 it was observed the 2nd floor Soiled Utility room door at the Recovery room was equipped with both a lever handle latchset and a combination latch/lock which requires two releasing operations to be conducted simultaneous to open the door. This arrangement does not comply with NFPA 101,7.2.1.5.10.6.

Based on observation during the survey walk-thru, means of egress are not maintained to provide a protected and unimpeded paths to exits. This deficient practice could affect patients, staff and visitors if a failure to provide required paths compromises access and level of safety for occupants.

Findings include:

A. On 11/2/16 at 11:15am while in the company of the VPO & POM2 it was observed that the corridor between the surgery area and the sterile processing area contained unattended equipment and materials consisting of a cart with supplies and/or delivery boxes, 3 floor scrubbers/equipment, and 3 surgery case carts. The stationing of these materials in the corridor reduces the available width of the corridor and does not comply with the requirements of NFPA 101, 19.2.3.4 and 19.2.3.5.

B. On 11/2/16 at 3:00pm while in the company of the VPO it was observed that Exit Passageways are not maintained to provide a protected path to the exit discharge. The east door of the pair of doors from the 302 Building that provides entry into the Exit Passageway did not close and latch to provide the required separation for the fire barrier wall upon activation of the fire alarm system to comply with NFPA 101,7.2.6.2.

Based on observation during the survey walk-thru, illumination of the exit discharge portion of the means of egress is not maintained. This deficient practice could affect patients, staff and visitors if failure to maintain illumination of the means of egress can cause delays in exiting during an emergency and preventing safe and unimpeded access to the public way.

Findings include:

On 11/1/16 at 1:40pm while accompanied by the VPO & POM2 it was observed that exterior building mounted lighting provided at the Cafeteria exterior door leading to the loading dock area and the corridor north of the Kitchen exit discharge doors leading to the loading dock area were not of an instant-on type to provide illumination within the required 10 second period to comply with NFPA 101 19.2.8 and 7.8.1.4 & 7.9.1.2.

Based on observations during the survey walk-thru and document review, emergency lighting is not tested and maintained. This deficient practice could affect patients, staff and visitors if failure to test and maintain the installed emergency lighting system can result in failure of the system to perform when needed during loss of normal power.

Finding include:

On 11/2/16 at 9:00am while in the company of the DSS it was observed that battery powered emergency lighting was provided for the facility. Documentation of periodic testing of the battery powered lighting system was requested to confirm compliance with 7.9.3.1.1. Per staff interview, annual testing for the 1.5 hour duration was not conducted and recorded to comply with 7.9.3.1.1(3) and (5).

Based on observation during the survey walk-thru, exit signs are not provided to identify access to at least two exits. This deficient practice could affect patients, staff and visitors, if a failure to mark available exit access paths can compromise access to available exits when the marked route may become unavailable during a fire or smoke event.

Findings include:

A. On 11/1/16 at 1:15pm while accompanied by the VPO & POM2 it was observed that only one path of exit access in the corridor north of the 2nd floor Sterile Processing suite was identified by exit signage. This does not comply with NFPA 101, 19.2.5.4.

B. On 11/1/16 at 1:50pm while accompanied by the VPO & POM2 it was observed that only one path of exit access in the corridor north of the Kitchen was identified by exit signage. This does not comply with NFPA 101, 19.2.5.4.

Based on observation during the survey walk-thru, exit signs are not provided to identify access to exits. This deficient practice could affect patients, staff and visitors if failure to mark exit paths can compromise access to available exits and prevent timely and efficient evacuation of the building during a fire/smoke event.

Findings include:

On 11/2/16 at 10:00am while accompanied by the VPO & POM2 it was observed that the main lobby serves as an exit access for areas beyond the main lobby. The exit sign provided above the exit access door through the vestibule was hidden by decorative ceiling construction and not visible from greater than 25 feet from the exit access door of the vestibule which does not comply with NFPA 101, 7.10.1.5.2 or 7.10.1.8.

Based upon direct observation, the facility failed to provide protection of vertical openings between floor levels. This deficient practice can affect patients, staff and visitors if the failure to protect vertical openings can lead to products of combustion spreading to other floor areas and compromise the safety of all the remaining building.
Findings include:
On 11/1/16 at 8:45 while in the company of the POCE, the Data Closet located within the bed storage room on the lower level of the bed tower contained an opening from a ventilation shaft from the 4th floor penthouse mechanical room that had fire dampers at the floor/ceiling level that was not sealed to form the bottom of the shaft. The data closet is not otherwise constructed to meet the rating of the shaft enclosure. NFPA 101, 8.6.5 and NFPA 90A, 2012, 5.3.4.

Based on document review and on site observations of hazardous areas, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation.

Findings include:

A. On 11/01/16, at 11:00 AM while accompanied by FM and DSS, in review of the Life Safety drawings on the North side of the Main Building, 1st floor, which indicated a 1-hour rated Soiled Utility Room by the Ambulance Bay near the Emergency Department. The room contained three unsealed conduit / pipe wall penetrations above the ceiling, over the left door leaf. This does not comply with NFPA 101, 8.3.5.1

B. On 11/01/16, at 11:10 AM while accompanied by FM and DSS, in review of the Life Safety drawings on the North side of the Main Building, 1st floor, which indicated a 1-hour rated Meds Supply Room across from Room 13 in the Emergency Department. The room contained unsealed conduit / pipe wall penetrations through all four walls above the ceiling. This does not comply with NFPA 101, 8.3.5.1.

C. On 11/01/16, at 1:30 PM while accompanied by FM and DSS, in review of the Life Safety drawings on the North side of the Main Building, 1st floor, which indicated a 1-hour rated Pyxis Supply Room for the Nursery. The room contained a hole and unsealed conduit / pipe wall penetrations in the wall above the ceiling. This does not comply with NFPA 101, 8.3.5.1.

D. On 11/01/16, at 1:40 PM while accompanied by FM and DSS, in review of the Life Safety drawings on the North side of the Main Building, 1st floor, which indicated a 1-hour rated Labor Par Room (storage room). An unsealed pipe penetration in the wall above the door was observed during the walk through. This does not comply with NFPA 101, 8.3.5.1.

E. On 11/01/16, at 1:46 PM while accompanied by FM and DSS, in review of the Life Safety drawings on the North side of the Main Building, 1st floor, which indicated a 1-hour rated Supply Room across from Room 147. Unsealed pipe penetration in the wall above the ceiling tile, next to the duct was identified during the walk through. This does not comply with NFPA 101, 8.3.5.1.

F. On 11/01/16, at 1:55 PM while accompanied by FM and DSS, in review of the Life Safety drawings on the North side of the Main Building, 1st floor, which indicated a 1-hour rated Labor and Delivery Supply Room. Unsealed penetrations in the wall above the ceiling tile were observed during the walk through. This does not comply with NFPA 101, 8.3.5.1.

Based on an observation during the survey walk-thru, hazardous areas are not enclosed with properly constructed fire barrier wall. This deficient practice could affect patients, staff and visitors if smoke or fire were not contained within a properly constructed fire barrier.

Findings include:

On 11/2/16 at 8:45am while in the company of the VPO & POM2 it was observed that 3 of 3 gas-fired furnace rooms in the basement which were provided with sprinkler protection were not adequately enclosed to provide containment of heat and smoke to permit the effective response for the sprinkler system to comply with 39.3.2.1, 8.7.1.1(2), 4.6.12.3 and NFPA 13-2010, 8.1.1. Holes in the ceiling drywall open to the floor joist space and shaft openings which extend to the attic were observed.

Based on observation during the survey walk-thru, Fire alarm systems are not properly installed. This deficient practice could affect patients, staff and visitors, failure to properly install the fire alarm system can compromise the ability of the system to provide notification to occupants of a fire/smoke event in the building.

Findings include:

On 11/2/16 at 8:45am while in the company of the DSS it was observed that the Fire Alarm Control Panel in the basement lacked identification of the electrical panel and circuit from which it was fed this does not comply with NFPA 72-2010, 10.5.5.2.1.

Based on observation during the survey walk-thru, fire alarm systems are not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can compromise the function and/or maintenance of the system intended to provide notification to occupants of a fire/smoke event in the building.

Findings include:

On 11/2/16 at 9:50am while in the company of the VPO & POM2 it was observed that the Fire Alarm Control Panel lacked identification of the electrical panel and circuit from which it was fed. This does not comply with NFPA 72, 2010, 10.5.5.2.1. The breaker serving the fire alarm control panel was not marked in red or provided with a lock-on device to comply with 10.5.5.2.3 & 10.5.5.2.4.

Based on observation during the survey walk-thru, the fire pull stations are not properly located. This could affect patients, staff and visitors of the areas served if the fire alarm system does not operate properly during a fire emergency.

Findings include:

On 11/2/16 at 8:45 AM while in the company of DSS, manual pull stations were not located within 5 feet of designated exit doorways at the North exit from the Classroom or adjacient to either designated exit door on the East side of the building to comply with NFPA 101, 9.6.2.3.

Based on observation during the survey walk-thru, smoke detection devices are improperly intalled. This deficient practice could affect patients, staff and visitors if the components are not installed in accordance with Code requirements, and the system could not provide effective warning to permit immediate response to a fire/smoke event.

Findings include:

On 10/31/16 at 3:15pm while in the company of the VPO & POM2 it was observed the smoke detection provided at the UPS room adjacent the basement level Data Center was not installed at the top of the room. This does not comply with NFPA 72-2010, 17.7.3.2.1.

Based on the fire alarm test, doors tied into the system failed to drop out and/or close completely. This deficient practice could affect patients, staff and visitors if the barrier failed to limit the spread of fire or restrict the movement of smoke from one side of the barrier to the other.

Findings Include:

On 11/1/16 at 3:15 PM while accompanied by FM and DSS, the cross corridor doors in the fire barrier wall between 2 North and 2 South, failed to close and latch during the activation of the fire alarm system. This does not comply with NFPA 101, 7.2.1.8

Based on observation and document review, not all areas are provided with sprinkler protection. This deficient practice could affect patient, staff and visitors if the failure to install the sprinkler systems in accordance with Code requirements can compromise the level of protection required to be provided.

Findings include:

On 10/31/16 at 2:30 PM while accompanied by FM, the Life Safety drawings of the Northwest side of the Main Building, Lower Level were reviewed. A 1-hour rated Electrical / Switchgear room was identified. The room was not provided with sprinklers protection, which does not meet with NFPA 13, 2010, 8.15.10.3.

Based on observation during the survey walk-thru, sprinkler systems are not properly installed. Failure to install and maintain the sprinkler system could affect patients, staff and visitors if failure of the sprinkler system allowed a fire to spread throughout the facility.

Findings include:

On 11/2/16 between 9:30am and 10:00am while in the company of the VPO & POM2 it was observed that typical electrical rooms lacked a ceiling or complete wall enclosure to the roof deck. This lack of a proper enclosure would allow the heat and smoke during a fire emergency to escape and prevent proper activation of the fire detection system. This does not comply with NFPA 101-2012, 4.6.12.3 and NFPA 13-2010, 8.1.1.

Based on observation, the facility failed to provide adequate protection of spaces open to the corridor. This condition could affect patients, staff and visitors if the means of egress is compromised due to the lack of protection for early notification of fire or smoke.

Finding includes:

A. On 10/31/16 at 3:00pm while accompanied by the VPO & POM2 it was observed the basement gated alcove containing wheeled equipment at the corridor leading to the 351 Building was not provided with smoke detection. This does not comply with NFPA 101, 19.3.6.1(1)c.

B. On 11/2/16 at 2:00pm while accompanied by the VPO & POM2 it was observed the Main Entry South lobby which contained a waiting seating area as a portion of the exit access corridor. The space was not provided with smoke detection to comply with NFPA 101, 19.3.6.1(7). The space exceeds the 600 square feet permitted under NFPA 101, 19.3.6.1(2) and 19.3.6.1(8) for waiting areas open to the corridor and lacks smoke detection at the high ceiling portion of the space.

C. On 11/2/16 at 2:00pm while accompanied by the VPO & POM2 it was observed the Main Entry South vestibule contained waiting seating and formed a portion of the exit access corridor was not provided with smoke detection to comply with NFPA 101, 19.3.6.1(7).

Based on observation during the survey walk-thruand review of the facility's life safety reference drawings, Corridor doors are not properly installed to latch. This deficient practice could affect patients, staff and visitors if failure of the corridor doors and the means of keeping the door closed compromises the means of egress corridor intended to provide a protected path of egress to an exit.

Finding include:

On 11/1/16 at 2:30pm it was observed while in the company of the DC & POM2 that the door to the Board room was not latching to keep the door closed to comply with NFPA 101, 19.3.6.3.5. The door accesses a staff-only corridor as defined by the facility's life safety reference plans.

Based on observation during the survey walk-thru, smoke barriers are not constructed to maintain the fire rating. This deficient practice could affect patients, staff and visitors if failure of the smoke barrier required fire rating can compromise the effectiveness of the barrier to provide an area of refuge for occupants.

Findings include:

On 11/1/16 at 10:15am while in the company of the VPO & POM2 it was observed the head of wall detail above the cross corridor doors in the smoke barrier at the north end of the 3-south corridor did not have full coverage of the intumescent spray material designed to seal and protect the mineral fiber installed at the metal deck flutes. The installation could not be confirmed to follow a tested design assembly to provide the minimum 1/2-hour fire rating required by NFPA 101, 19.3.7.3.

Based on observation during the survey walk-thru, doors in smoke barrier walls are not maintained to resist the passage of smoke. This deficient practice could affect patients, staff and visitors if failure to maintain doors to resist the passage of smoke can compromise adjacent smoke compartments intended to provide protection from the effects of smoke conditions.

Findings include:

On 11/1/16 at 10:50am while in the company of the VPO & POM2 it was observed that the 2nd floor smoke barrier cross corridor doors at the north end of the corridor between the ICU and Recovery had a vertical rod latch bolt which extended to the latched condition while the door was open and did not allow the door to fully close when released from the magnetic hold-open device to comply with NFPA 101, 19.3.7.8 and 8.5.4.1.

Based on document review and interview, the facility failed to conduct fire drills at varied times. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

Findings Include:

On 10/31/16, at 1:15 PM during document reviews, it was determined that the facility's quarterly fire drills do not meet the requirement of varying times in all three shifts throughout the annual cycle. Fire drills should vary a minimum of 2 hours for all four quarters on each shift. The following fire drills listed below are the shifts and quarters that are deficient based on NFPA 101, 19.7.1.6.

1st Shift: (7 AM to 3:30 PM)
01/12/16 @ 7:40 AM
04/05/16 @ 7:45 AM
07/07/16 @ 7:30 AM
10/04/16 @ 8:00 AM

2nd Shift (3:00 PM to 11:30 PM)
02/02/16 @ 2:35 PM
05/03/16 @ 3:00 PM
08/02/16 @ 3:00 PM
11/03/15 @ 3:00 PM

3rd Shift (11:00 PM to 7:30 AM)
03/02/16 @ 11:25 PM
06/01/16 @ 10:30 PM
09/06/16 @ 10:06 PM
12/09/15 @ 11:14 PM

Based on observation, the facility failed to provide the electrical system in accordance with Code requirements. This deficient practice could affect patients, staff and visitors if failure to install and maintain the electrical system leads to electrical hazards or failure of the system to perform as required.

Findings include:

A. On 10/31/16 at 2:30 PM, while accompanied by the POM1, it was observed that generator #1 was not equipped with a remote manual stop station in accordance with the 2010 Edition of NFPA-110, Section 5.6.5.6.

B. On 11/1/16 at 9:25 AM, while accompanied by the POM1, it was observed that life safety panels BWL1 and 2NWEL1 were serving loads that are not allowed to be served from the life safety branch of emergency power to comply with the 2012 Edition of NFPA-99, Section 6.4.2.2.3.

C. On 11/1/16 at 1:30 PM, while accompanied by the POM1, it was observed that the C-section rooms were not equipped with normal power receptacles or receptacles served from two separate critical transfer switches as required by the 2012 Edition of NFPA-99, Section 6.3.2.2.1.2, and that the C-section rooms were not equipped with battery lighting to meet the requirements of the 2012 Edition of NFPA-99, Section 6.3.2.2.11.

D. On 11/1/16 at 10:15am while in the company of the VPO & POM2 it was observed that the head of wall detail above the cross corridor doors in the smoke barrier at the north end of the 3-south corridor contained an open electrical box at this location which does not comply with NFPA 70-2011.

Based on observation, the facilities did not install ground fault circuit interupt (GFCI) receptacles in wet areas. This deficient practice could could affect any occupant of the facility if proper safety precautions are not met when electrical systems are installed.

Findings include:

On 10/31/16 at 3:30 PM, while accompanied by FM, during the walk through of the Center Main Building, Lower Level, Laboratory, it was noted that the work stations contained several duplex receptacles. A water basin located along the main aisle was adjacent to receptacles identified as circuits 41 & 43 and within 6 feet from the edge of the water basin. The receptacles were not a GFCI manufactured device and per inspection of the electrical panel the receptacles were not on a GFCI breaker per NFPA 99, 2012, 6.3.2.2.8.

Based on observation during the survey walk through the receptacles in critical care locations were not properly labeled. This could affect patients, staff and visitors being treated in these areas if a circuit breaker trips and can't be located promptly.

Findings include:

On 11/1/16 at 10:00 AM, it was observed the critical outlets in the ICU and the PACU rooms were not labeled to identify the panel and circuit from which they are fed to comply with the 2011 Edition of NFPA-70, Section 517-19.

Based on observation during the survey walk-thru and document review of the Essential Electrical Systems (EES) are not properly maintained. Failure to maintain the EES can result in failure of the system which could affect patients, staff and visitors if improper maintenance prevented the ESS from activating during the loss of normal power.

Finding include:

On 11/2/16 at 11:00am while in the company of the DSS it was observed during review of the generator testing that testing information was not being tabulated on the forms correctly or consistently. The generator serves as the required back-up power source for the exit lighting in accordance with NFPA 101, 7.10.5.2. The time delay to start the engine was tabulated as less than the time delay to transfer load to the generator. Multiple entries during previous monthly testing exceeded the 10 second delay required by 7.9.2.2 and NFPA 110-2010, 4.1.